How 'Cool' is heroin injection at the Kenya coast

Qualitative research methods were used to contact, observe and interview about 40 heroin users living in a Kenyan coastal town with a lively tourist industry. It was found that injecting practices were similar to those reported in other parts of the world. High status, or 'cool', among heroin users was associated with injecting alone and with personal autonomy. The sharing of injecting equipment, however, did occur. Most users were ill informed about the risk of transmission of HIV through injecting equipment. Injecting heroin can be status enhancing within this subculture. 'Cool' among these heroin users was associated with personal self-control, a key attribute of Swahili culture. Intervention measures should build on local values of the need to maintain individual self-control and discourage the sharing or communal use of equipment to inject heroin.     

How ‘Cool’ is heroin injection at the Kenya coast

Qualitative research methods were used to contact, observe and interview about 40 heroin users living in a Kenyan coastal town with a lively tourist industry. It was found that injecting practices were similar to those reported in other parts of the world. High status, or ‘cool’, among heroin users was associated with injecting alone and with personal autonomy. The sharing of injecting equipment, however, did occur. Most users were ill informed about the risk of transmission of HIV through injecting equipment. Injecting heroin can be status enhancing within this subculture. ‘Cool’ among these heroin users was associated with personal self-control, a key attribute of Swahili culture. Intervention measures should build on local values of the need to maintain individual self-control and discourage the sharing or communal use of equipment to inject heroin.     

A comparison of the harms associated with the injection of heroin and amphetamines

An investigation into whether or not the level of harm associated with injecting drug use varies depending on the drug that is injected was conducted among 151 primary heroin injectors and 145 primary amphetamine injectors. Compared to primary amphetamine injectors, primary heroin injectors were more dependent on their primary drug, had poorer social functioning, and had recently exhibited a higher degree of criminal behaviour. There were no differences between the two groups in terms of the prevalence of needle sharing, their health, or their psychological functioning, despite the amphetamine users being significantly younger and having used less frequently. It is concluded that while there are some harms that are attributable to injecting per se, the type of drug that is injected does play a mediating role in the relationship between injecting drug use and its associated harm.     

Changes in the initiation of heroin use after a reduction in heroin supply

Increasing heroin use in Australia over the past 30 years has been associated with a decline in the age of initiation to heroin use. The 2001 Australian heroin shortage was used to assess the effects of a reduction in heroin supply on age of initiation into heroin injecting. Data collected from regular injecting drug users (IDU) over the period 1996 - 2004 as part of the Australian Illicit Drug Reporting System were examined for changes in self-reported age of first heroin use after the onset of the heroin shortage. Estimates were also made of the number of young people who may not have commenced injecting heroin during the heroin shortage. The proportion of IDU interviewed in the IDRS who were aged ≤24 years decreased from 46% in 1996 to 12% in 2004, with the most marked drop in 2001, the year in which there was an abrupt and marked reduction in heroin availability. Of those who reported first injecting between 1993 and 2000, similar proportions reported heroin and amphetamine as the first drug injected. After 2000, methamphetamine was the drug most often reported as being the first injected. Estimates suggested that between 2745 and 10 560 young people may not have begun to inject heroin in 2001 as a result of reduced heroin supply. If around one in four of these young users had progressed to regular or dependent heroin use, then there may have been a reduction of between 700 and 2500 dependent heroin users. There was an increase in amphetamine injecting but it is unclear to what extent any reduction in heroin injecting has been offset by increased amphetamine injecting. Reduced heroin availability probably resulted in a reduction in the number of new heroin injectors in Australia. Efforts need to be made to reduce the chances that young people who have initiated methamphetamine injecting do not move to heroin injecting when the heroin supply returns. [Day C, Degenhardt L, Hall W. Changes in the initiation of heroin use after a reduction in heroin supply. Drug Alcohol Rev 2006;25:307 - 313]     

Reawakening the dragon: changing patterns of opiate use in Asia, with particular emphasis on China's Yunnan province

Asian countries adjacent to the Golden Triangle and their neighbors have witnessed an evolution in "drug abuse" from traditional opium smoking to heroin eating, smoking, and finally heroin injection. A recent study of 630 heroin users was conducted in China's Yunnan Province, located close to the Golden Triangle. Data collected between August 1997 and February 1998 indicate injecting heroin users, in comparison to noninjectors, were more likely to have used drugs for a longer period of time, and to use drugs more frequently everyday. Other major differences existed between urban and rural subjects, especially highlighting differences between men and women. Women comprised a much higher proportion of urban subjects than rural subjects. Rural injectors were much more likely to be male, but urban injectors were almost evenly split between men and women. The emerging epidemic of heroin use in China and the continuing substance abuse problem in the United States provide an opportunity for collaborative research of mutual benefit.     

Differences in Characteristics of Heroin Inhalers and Heroin Injectors at Admission to Treatment: A Preliminary Study Using a Large Database of Client Records

Aims.?To compare the characteristics of heroin injectors vs. inhalers at their first admission to publicly funded treatment in Texas. Methods.?The sample consisted of 9732 unique clients who entered publicly funded treatment programs in Texas between 1997 and 2001 and who had a primary problem with either injected or inhaled heroin, which they had used in the past 30 days. The records were analyzed using a generalized linear model of logistic regression with the outcomes modeled as binomial and multinomial distribution and a hierarchical linear model for continuous outcomes to compare heroin inhalers and injectors. Findings.?There were large statistically significant differences between injectors and inhalers. Inhalers were more likely to be older at first use of heroin, to have entered treatment sooner, to have minor children at home, to have higher annual incomes, to be first admissions to treatment, and to have a secondary drug problem with crack cocaine. They were also more likely to be Hispanic [odds ratio (OR) = 1.74] or African-American (OR = 12.32). Conclusions.?Even though the race/ethnic differences in the Texas population and the type of heroin available for use in Texas differs from that studied elsewhere, many of the characteristics of heroin users are similar. Inhalers have more strengths in many areas, and these findings raise the possibility that there are factors, particularly among African-American participants in Texas, that lessen the risk of injecting heroin. Efforts should be directed to providing therapeutic interventions to discourage the transition to injecting and to encourage inhalers to enter treatment earlier rather than progressing on to injecting. This analysis is the first part of a larger study of heroin users in public and private treatment.     

Differences in characteristics of heroin inhalers and heroin injectors at admission to treatment: a preliminary study using a large database of client records

AIMS: To compare the characteristics of heroin injectors vs. inhalers at their first admission to publicly funded treatment in Texas. METHODS: The sample consisted of 9732 unique clients who entered publicly funded treatment programs in Texas between 1997 and 2001 and who had a primary problem with either injected or inhaled heroin, which they had used in the past 30 days. The records were analyzed using a generalized linear model of logistic regression with the outcomes modeled as binomial and multinomial distribution and a hierarchical linear model for continuous outcomes to compare heroin inhalers and injectors. FINDINGS: There were large statistically significant differences between injectors and inhalers. Inhalers were more likely to be older at first use of heroin, to have entered treatment sooner, to have minor children at home, to have higher annual incomes, to be first admissions to treatment, and to have a secondary drug problem with crack cocaine. They were also more likely to be Hispanic [odds ratio (OR) = 1.74] or African-American (OR = 12.32). CONCLUSIONS: Even though the race/ethnic differences in the Texas population and the type of heroin available for use in Texas differs from that studied elsewhere, many of the characteristics of heroin users are similar. Inhalers have more strengths in many areas, and these findings raise the possibility that there are factors, particularly among African-American participants in Texas, that lessen the risk of injecting heroin. Efforts should be directed to providing therapeutic interventions to discourage the transition to injecting and to encourage inhalers to enter treatment earlier rather than progressing on to injecting. This analysis is the first part of a larger study of heroin users in public and private treatment.     

REAWAKENING THE DRAGON: CHANGING PATTERNS OF OPIATE USE IN ASIA,WITH PARTICULAR EMPHASIS ON CHINA'S YUNNAN PROVINCE

Asian countries adjacent to the Golden Triangle and their neighbors have witnessed an evolution in “drug abuse” from traditional opium smoking to heroin eating, smoking, and finally heroin injection. A recent study of 630 heroin users was conducted in China's Yunnan Province, located close to the Golden Triangle. Data collected between August 1997 and February 1998 indicate injecting heroin users, in comparison to noninjectors, were more likely to have used drugs for a longer period of time, and to use drugs more frequently everyday. Other major differences existed between urban and rural subjects, especially highlighting differences between men and women. Women comprised a much higher proportion of urban subjects than rural subjects. Rural injectors were much more likely to be male, but urban injectors were almost evenly split between men and women. The emerging epidemic of heroin use in China and the continuing substance abuse problem in the United States provide an opportunity for collaborative research of mutual benefit. [Translations are provided in the International Abstracts Section of this issue.]     

Changes in route of drug administration among continuing heroin users: outcomes 1 year after intake to treatment

This study investigates the type and extent of changes in route of drug administration among heroin users after treatment: whether injectors move to other routes of use; whether changes in route for one drug influence routes used for other drugs; and associations between changes in route of administration and other substance use outcomes. The sample comprised 641 heroin users recruited to 54 UK treatment programmes. At intake, the main routes of heroin use were injecting (61%) and "chasing the dragon" (37%). After 1 year, 81% of those using heroin took it by the same route as at intake, while 19% reported a change, with 14% switching from injecting to chasing. Changes from injecting to chasing were associated with improvements in other substance use behaviours. Changes in route represent an important aspect of drug-taking behaviours. Interventions to prevent the change to injecting should be developed and offered to noninjectors. "Reverse transitions" (from injecting to chasing) may represent a useful intermediate treatment goal for drug injectors who cannot achieve abstinence.     

Polydrug Use and HIV Risk Among People Who Inject Heroin in Tijuana,Mexico: A Latent Class Analysis

Background: Although most people who inject drugs (PWID) in Tijuana, Mexico, primarily inject heroin, injection and non-injection use of methamphetamine and cocaine is common. We examined patterns of polydrug use among heroin injectors to inform prevention and treatment of drug use and its health and social consequences. Methods: Participants were PWID residing in Tijuana, aged ≥18 years who reported heroin injection in the past six months and were recruited through respondent-driven sampling (n = 1,025). Latent class analysis was conducted to assign individuals to classes on a probabilistic basis, using four indicators of past six-month polydrug and polyroute use: cocaine injecting, cocaine smoking or snorting, methamphetamine injecting, and methamphetamine smoking or snorting. Latent class membership was regressed onto covariates in a multinomial logistic regression. Results: Latent class analyses testing 1, 2, 3, and 4 classes were fit, with the 3-class solution fitting best. Class 1 was defined by predominantly heroin use (50.2%, n = 515); class 2 by methamphetamine and heroin use (43.7%, n = 448), and class 3 by methamphetamine, cocaine, and heroin use (6.0%, n = 62). Bivariate and multivariate analyses indicated a group of methamphetamine and cocaine users that exhibited higher-risk sexual practices and lower heroin injecting frequency, and a group of methamphetamine users who were younger and more likely to be female. Conclusions: Discrete subtypes of heroin PWID were identified based on methamphetamine and cocaine use patterns. These findings have identified subtypes of heroin injectors who require more tailored interventions to reduce the health and social harms of injecting drug use.     

Transition to injection and sharing of needles/syringes: potential for HIV transmission among heroin users in Chengdu, China

This cross-sectional survey interviewed heroin injectors admitted in three detoxification centres from August 2003 to June 2004 in Chengdu City, China. Logistic regression and survival analysis were performed to identify factors associated with sharing of needles/syringes and time from initiation of heroin to adoption of injection, respectively. Out of 266 subjects studied, 206 (77.44%) were males, 103 (38.72%) never shared injecting materials, 113 (42.48%) were non-Chengdu residents and 9 (3.38%) belonged to ethnic minorities. Those with short history of heroin injection (P<0.05) and those belonged to ethnic minorities (P<0.05) were more likely to share injecting materials. Only age, ethnicity and duration of heroin use were associated with time to first injection. Median time to injection was 6 months for those who used heroin for the duration up to 1 year and 21 months for those who used heroin for 2-5 years. The study suggests that there is early initiation of injection and sharing of injecting materials is high among heroin users, a major risk for HIV transmission. Ethnic minorities have been identified to be the most risky group, which needs further attention.     

Working with heroin sniffers: clinical issues in preventing drug injection

Preventing illicit drug injection would be the ideal point for preventing HIV infection and AIDS among illicit drug injectors. This paper reports on clinical issues that arose in a program for intranasal ("sniffer") heroin users who were at high risk of injecting drugs. Extensive field notes were kept by the staff of the project. A generalized mistrust of authorities, denial of problems associated with non-injected drug use, and ambivalence about injecting were the major issues that arose during subject recruitment and the group sessions. The staff underwent trial and error learning, both becoming more confident in working with heroin sniffers, and finding better results for later participants in the study.     

Increasing popularity of injection as the route of administration of amphetamine in Edinburgh

Six hundred and thirty four interviews of injecting drug users were performed between 1992 and 1994 as part of a study of injecting drug use and HIV prevalence in Edinburgh, Scotland. Amphetamine was injected by more subjects (44%) than any other drug. Preference for injection as the route of administration of amphetamine increased over the period despite no change in the popularity of the drug generally. Simultaneously, heroin use and injection declined. Analyses indicated that amphetamine injectors comprised two distinct sub-groups. The majority were polydrug injectors who injected frequently, had a longer injecting history and were more likely to share injection equipment. About one-fifth were stimulant-only injectors who injected infrequently, were relatively recent initiates to injecting and whose numbers increased over the 3 years. Drug treatment and prevention services may need to explore alternative methods to respond effectively to these emerging trends.     

Characteristics and harms associated with injecting versus smoking methamphetamine among methamphetamine treatment entrants

Introduction and Aims. To compare the characteristics and harms associated with injecting and smoking methamphetamine among methamphetamine treatment entrants. Method and design. A structured face-to-face interview was used to assess demographics, drug use patterns and harms [physical and mental health, psychological distress, psychotic symptoms, crime and human immunodeficiency virus (HIV) risk behaviour] among 400 methamphetamine treatment entrants in Sydney and Brisbane, Australia. Participants who had injected but not smoked methamphetamine in the month before treatment (n = 195, injectors) were compared to participants who had either: (a) injected and smoked (n = 90, injectors who smoke), or (b) smoked but not injected (n = 73, smokers), during this time. Results. In comparison with injectors, smokers were primarily non-injecting drug users, who were younger, more likely to be female and use ecstasy rather than heroin. After adjusting for these differences smokers were less dependent on methamphetamine than injectors, but they took the drug as often and had similarly high levels of psychological distress, poor physical and mental health, psychotic symptoms, sexual risk behaviour and criminal involvement. Injectors who smoked had a similar demographic and clinical profile to injectors, including comparable levels of needle sharing, but they used methamphetamine more often and had greater criminal involvement. Conclusion. Within this treatment sample, smoking methamphetamine occurred among both long-standing injecting drug users and a comparatively younger group of non-injecting drug users. It was associated with less severe methamphetamine dependence than injecting, but more intense use patterns and similar levels of other harms. [McKetin R, Ross J, Kelly E, Baker A, Lee N, Lubman DI, Mattick R. Characteristics and harms associated with injecting vs. smoking methamphetamine among methamphetamine treatment entrants. Drug Alcohol Rev 2008;27:277-285]     

A rapid assessment of heroin use in Mombasa, Kenya

This article reports on a rapid assessment (RA) carried out in the city port of Mombasa, Kenya in March 2004 by the Omari Project to inform the scaling up of their services to heroin users. Heroin has been a street drug in Mombasa for over 25 years. From 1998, white crest, probably from Thailand, started to replace brown sugar, and there was a major shift from inhalation of the vapor ("chasing the dragon") to injecting. The Omari Project has been monitoring the heroin situation in Mombasa and treating heroin users from Mombasa since 1997. In the course of the RA, 496 heroin users were interviewed of whom 95% were men and 5% were women. A range of methods were used, including mapping of the Mombasa region, work with a key informant/guide who was a heroin user, administration of a brief questionnaire and informal interviews, and feedback of findings to other local agencies working with drug users. Respondents were from a wide range of cultural/ethnic groups, the two largest being Mijikenda and Swahili, who are indigenous to the Kenya coast. Overall, 15% of respondents had "ever injected" heroin, and 7% were current injectors (n = 37). These data indicate a shift away from injecting but also reflect the death of many established injectors, either through overdose or AIDS or hepatitis. The figure of 7% of the sample reporting being current injectors is likely to be an underestimate. Syringes were available from a number of pharmacies and most injectors reported using a syringe for 1-3 days. The majority reported injecting in a group of three or more and described risk behaviors for HIV transmission. The results of the assessment highlight the need for a range of services, including needle exchange, counseling, and referral to residential treatment programs. However, progress toward responding to the findings of the RA by establishing effective services are hampered because of legal impediments to operating needle exchange programs in Kenya.     

The Differences between Male and Female Drug Users: Community Samples of Heroin and Cocaine Users Compared

Although gender-related issues are often cited as playing an important part in determining patterns of illicit drug use, little is known about me differences between male and female drug users outside treatment settings. In the present study, 558 heroin and cocaine users recruited from a range of community settings were interviewed by Privileged Access Interviewers. The women were found to be younger than the men. Differences existed in their drug use; women used smaller amounts, for a shorter duration, and were less likely to inject than their male counterparts. No differences existed between treatment contact for the heroin users, but differences were found among die cocaine-using sample, with men being more likely to have contacted a treatment agency. Men were financing themselves through more criminal activities than women. Drug-using sexual partners were found to be an important influence over women's drug use, with most female injectors having been given their first injection by a male sexual partner. Structural differences in patterns of drug use found among female drug users and the influence of male sexual partners are likely to play an important role in determining appropriate treatment options for women drug users.     

A Rapid Assessment of Heroin Use in Mombasa,Kenya

This article reports on a rapid assessment (RA) carried out in the city port of Mombasa, Kenya in March 2004 by the Omari Project to inform the scaling up of their services to heroin users. Heroin has been a street drug in Mombasa for over 25 years. From 1998, white crest, probably from Thailand, started to replace brown sugar, and there was a major shift from inhalation of the vapor (“chasing the dragon”) to injecting. The Omari Project has been monitoring the heroin situation in Mombasa and treating heroin users from Mombasa since 1997. In the course of the RA, 496 heroin users were interviewed of whom 95% were men and 5% were women. A range of methods were used, including mapping of the Mombasa region, work with a key informant/guide who was a heroin user, administration of a brief questionnaire and informal interviews, and feedback of findings to other local agencies working with drug users. Respondents were from a wide range of cultural/ethnic groups, the two largest being Mijikenda and Swahili, who are indigenous to the Kenya coast. Overall, 15% of respondents had “ever injected” heroin, and 7% were current injectors (n = 37). These data indicate a shift away from injecting but also reflect the death of many established injectors, either through overdose or AIDS or hepatitis. The figure of 7% of the sample reporting being current injectors is likely to be an underestimate. Syringes were available from a number of pharmacies and most injectors reported using a syringe for 1–3 days. The majority reported injecting in a group of three or more and described risk behaviors for HIV transmission. The results of the assessment highlight the need for a range of services, including needle exchange, counseling, and referral to residential treatment programs. However, progress toward responding to the findings of the RA by establishing effective services are hampered because of legal impediments to operating needle exchange programs in Kenya.     

Combining Quantitative and Qualitative Approaches: Researching Hiv-Related Risk Behaviours Among Drug Injectors

Research into complex social behaviours, like injecting drug use, rarely combines quantitative and qualitative techniques. Qualitative researchers have tended to show a reluctance to become familiar with the terminology and practice of quantitative methods, whereas quantitative researchers have been mistrustful of data not numerically codified. Data from two independent studies on the HIV-related risk behaviours of injecting drug users in Glasgow show the possible benefits of integrating the two methodologies. Structural equation modeling (SEM) on a large quantitative data set indicated that female injectors were more likely to share unsterile injecting equipment although they had greater knowledge about HIV transmission than males. Qualitatively elicited data were able to elucidate the social processes creating and sustaining risk behaviours reported by injectors.     

Overdosing among young injection drug users in San Francisco.

Heroin overdoses increased sharply in the US in the 1990s, but few studies have addressed overdose risk. We examined overdosing and injection-related risk behavior in young injection drug users (IDUs). We interviewed all consenting injectors under age 30 at needle exchanges and youth outreach sites in San Francisco. Their median age was 22, and their median number of years of injecting was 4. About 48% reported at least one overdose, with a median of two overdoses reported. Overdosing was associated with injecting "speedballs" (i.e. mixtures of heroin and cocaine), with borrowing syringes, and (with P-values of borderline statistical significance) with heroin injection and with gay or bisexual behavior. It was not associated with age, sex, years of injecting, or frequency of injecting. In multivariate analysis, only borrowing syringes and gay or bisexual behavior were independent statistically significant predictors, probably because gay and bisexual subjects were more likely to be heroin or "speedball" injectors. Most subjects (65%) reported that they had not received medical attention at time of last overdose. Risk of overdose in young injectors is acute and closely associated with HIV risk. HIV interventions should include overdose prevention. Emergency response protocols should minimize risk of arrest. Injectors and providers should be trained in overdose prevention, and developing overdose interventions should be a priority among drug educators.